Clinical

baby will only require around one teaspoon of the birth. A poor diet can reduce the nutrient per feed due to its high concentration.9 stores for the mother, as any form of nourishment After 2-3 days postpartum, is prioritised for the baby.15 Module 1971 increases significantly in volume, with the start In England, around 80% of women will of any feed containing much more fluid and the breastfeed in the first instance, as stated by the end changing to become much more energy and Royal College of Paediatrics and Child Heath.16 The role of nutrition in nutrient rich.10 Colostrum promotes the expulsion However, only 45% exclusively breastfeed of meconium; the black, tar-like faeces produced one week after birth and only 21% at six infants after the baby is born.11 weeks.6 Approximately 10% of newborns are not breastfed within the first hour of life, as From this CPD module you will learn: Breast milk composition recommended by WHO.17 • The role of nutrition in infants Approximately 40-55% of total energy in breast reduces the incidences of milk is comprised of lipids. Lipids are presented in common childhood illnesses including ear, chest • Benefits and rates of breastfeeding breast milk as milk fat lipid globules, which form and gut infections, as well as the development of • as an alternative to breastfeeding the structure of the milk. As well as providing atopic conditions such as eczema, asthma and hay over 200 fatty acids to the infant, lipids have fever. Treating these conditions in infants costs • The role of the pharmacy team also shown to aid in the full development of the National Health Service (NHS) approximately the gastrointestinal tract.5 The lipids are also £50 million each year.14 necessary for brain, nervous system and retinal Some mothers are unable to or have difficulty maturation.12 The high content of lipids ensures breastfeeding. For example, if a mother is on MALA MAHASURIA, PHARMACIST infant nutrition tends to begin with breast milk, that the infant is sated but also ensures that certain medications, undergoing chemotherapy especially during the first six months of life. energy is supplied for adequate growth.10 or taking antiretroviral therapy for HIV infection, The pharmacy is an ideal environment for parents Following on from this, a combination of breast Breast milk also contains . breastfeeding is contraindicated, as these to obtain reliable and evidence-based information milk and solids should be initiated between six Colostrum in particular has an abundant supply when it comes to caring for their baby. Infant months and two years of age, as recommended of antibodies, particularly immunoglobulin nutrition is not just about breastfeeding by the World Health Organisation (WHO).3,4 A, which plays a key role in the mucus nowadays. With a vast range of infant formula membranes.13 Proteins, vitamins and non- milk available and with current advice stating The role of breast milk protein nitrogen also play key roles in that a parent should always speak to a healthcare Breast milk is a biological fluid comprised of a providing essential nutrition, mucosal professional in the first instance, it is imperative tailored set of nutrients, energy, immunity and repair and immunity.10 that all pharmacy team members are kept up to growth factors provided to the baby throughout date with the latest information. infancy.5 The components of breast milk adapt Benefits and risks of to the needs of the infant as it grows. Breast milk breastfeeding Why is nutrition important? can protect infants from disease by providing For the mother, breastfeeding Adequate nourishment is vital for development immunisation. It can also inhibit inflammation, can reduce the risk of diabetes and wellbeing.1 Nutrition is important for creating advance production and can provide by 30% and hypertension by strong a immune system, supporting brain the immune system with the ability to recognise 13%.14 It can stimulate uterine development and increasing both length and microorganisms in the respiratory tract and gut.6 contraction, meaning better quality of life. Good nutrition can lower the risk post-partum weight loss and of modifiable diseases such as obesity, type 2 Colostrum increased uterine tone. If a diabetes and high cholesterol along with other Breast milk constantly adapts to the needs of the mother is solely breastfeeding, cardiovascular complications.2 infant. Colostrum is described as breast milk that she could burn as many as 500 The requirements of macro/micronutrients, is produced during the first few days of life. It has calories per day.1,11 It is imperative vitamins, minerals and water varies at each stage a large concentration of antibodies compared to that the mother eats well during of development and it is widely recognised that regular breast milk and is much less diluted.7,8 The pregnancy as well as following

chemistanddruggist.co.uk/update-plus March 2021 | Module 1971 | The role of nutrition in infants | 1 of 5 medications are all present in the breast milk. difficult to make an informed decision. There are Other reasons to not breatfeed include not two different types; dry powder, which requires producing enough milk, returning to work and the addition of water, or ready-to-feed bottles.20 being unable to express milk or for religious It is important to also know that the formula reasons. The baby may be unable to latch on to milk industry has to comply with European law, the breast properly or the breasts can become which sets out the nutritional composition for engorged and painful making breastfeeding manufactures to adhere to. The composition difficult.18 For whatever reason a mother is must comprise of protein, fats, carbohydrates, unable to feed, there are plenty of infant formula vitamins and minerals. However, producers options on the market, as pure cows’ milk is can develop their own combinations within not recommended for babies under 12 months these guidelines.21,22 of age.19 First infant formula Infant formula milk First infant formula (first milk) unless stated The Department of Health states that infant otherwise by a midwife, health visitor or GP, is the formula can be used alone for the first six only milk the baby needs for the first six months months. Infant formula milks should only be used and up to one year. After this, the infant can be Equipment for bottle feeding should be washed in cold water prior to sterilisation if recommended by an appropriate healthcare switched to pasteurised cows’, goats’ or sheep’s professional. milk.23,24 First infant formula based on whey Other milks Cleaning and sterilising It is impossible to replicate breast milk and with protein is thought to be easier to digest than other • Lactose free – although lactose intolerance It is important to sterilise all equipment used a wide range of brands on the market, it can be types of formula.24 is rare in babies, it can cause abdominal pain, when bottle feeding. This is to prevent the Goats’ milk formula is also an option but is not bloating and diarrhoea.19 development of infections, vomiting and recommended as an alternative if the infant has a • Hungrier baby – while there is no evidence to diarrhoea. Bottles, teats and other equipment cows’ milk allergy due to the similarity in proteins suggest that infants are sated after using this must be washed in hot, soapy water as soon as shared by both types of milk. formula, hungry milk contains more casein than possible after feeds. Specific brushes for the whey, which takes longer to digest.19 bottle and teat are preferred but a dishwasher Comfort and hypoallergenic milk • Follow-on – fed from six months and older can be used, although it should be emphasised Comfort milk is when the proteins in the milk are only, research shows that there is no benefit to that they are not sterile at this point with either partially hydrolysed meaning that the proteins switching to this milk at six months.19 method.25 in cows’ milk is broken down slightly to make the • Good night – with added cereal, this is The equipment must be then washed in cold amino acid chains smaller. The shorter the protein designed to be given at bedtime. There is no water prior to sterilising. There are three options chains, the easier it is for the milk to be digested evidence to suggest that infants sleep better for sterilising; cold water, steam or boiling.25 and therefore there may be a reduction in after being fed this milk.19 Cold water sterilising: An example is Milton digestive problems such as colic and constipation. • Growing up – there is no evidence to suggest sterilising fluid, which is commonly sold in Hypoallergenic milk is fully hydrolysed and is this provides better nutrition than regular milk pharmacies. The equipment is steeped in this fluid indicated for infants with cows’ milk allergies. for toddlers aged one year and above. for 30 minutes. There should be no air bubbles • Soya – this is only suitable from six months present so that every section is fully sterile. Milton Anti-reflux formula old and only under medical supervision. sterilising fluid should be changed every 24 hours. This formula is thickened to reduce the incidences This is occasionally used in those who have Steam: Steaming involves the purchasing of a of severe reflux in infants. Anti-reflux formulas a cows’ milk allergy. However, due to the device and following manufacturer instructions are usually reconstituted at lower temperatures content of phytoestrogens there are some on how to steam. The equipment should be left than normal formulations because they can concerns that consumption can affect the in this device until they are next required but become lumpy. Care must be taken when using babies’ reproductive system. Soya formula also there is a limit to the duration that they can be left Infant formula can be used alone for the first this formula because the lower temperatures may contains glucose, and can therefore cause harm before they need sterilising again. The equipment six months not kill any harmful bacteria. to the baby’s teeth.19 should be upside down.

chemistanddruggist.co.uk/update-plus March 2021 | Module 1971 | The role of nutrition in infants | 2 of 5 Boiling: The equipment should be boiled for Foods to avoid Allergies formula milks is vital for giving the correct advice, at least 10 minutes, ensuring they stay under the • Honey can contain a toxin that causes botulism Foods such as cows’ milk, eggs, gluten, soya, especially because most parents will require surface at all times. Using this method means the in those under 12 months. This should be fish and shellfish, nuts and seeds should be advice from a healthcare professional before teats can become damaged much more quickly. completely avoided. Botulism attacks the introduced slowly in small quantities on a switching to formula. It is quite apparent that nervous system, leading to symptoms such repeated basis, if tolerated.26 there is a huge variety of infant formula, which Weaning as blurred vision, facial muscle weakness and can be extremely overwhelming; it is really useful Weaning, or complementary feeding, is the difficulty swallowing. Baby-led weaning for the mother to make an informed decision with introduction of solids to an infants diet in • Unpasteurised drinks and food can contain Rather than spoon feeding during mealtimes, trusted advice. Although most infant milks can be conjunction with breast milk or infant formula. Escherichia coli and therefore should be baby-led weaning involves finger foods that the purchased over-the-counter, if first infant formula It allows the baby to explore the chewing, avoided, as they can cause diarrhoea. infant can grasp and bring to their mouth in is not suiting a baby, referral to a GP, midwife or moving and swallowing of solid foods. It is easily • Fortified cows’ milk can lead to intestinal order to feed themselves. The potential benefit health visitor is important to ensure the safest misinterpreted that an infant is ready for weaning bleeding as it contains too many proteins and is that the infant can choose and explore food type is prescribed or recommended based on that if they are chewing their fists, want extra milk can harm immature kidneys. independently and therefore become less fussy. individual needs of the baby. or they are waking up more than usual. Actual • Juices and ready prepared meals should be Some research suggests that babies who feed Pharmacies are an important place for signs are more practical, such as holding their avoided due to the high sugar and salt content.28 themselves are less likely to overeat, reducing signposting parents to appropriate and reliable head steady, good hand to eye co-ordination chances of obesity in the future, although information on all things related to nutrition and and swallowing milk rather than spitting it up. evidence is limited. feeding. The NHS website contains a vast amount At approximately six months, the need for There is some concern that there is an of information on these topics. The National more than just milk will be apparent. How much increased risk of choking with baby-led weaning Childbirth Trust (NCT) is a charitable organisation solid food is the correct amount to consume is but there is no evidence to support this. Babies that only provides information sourced from individual to the infant.26 have a very strong gag reflex, in which they will be Nice or the NHS. All research is broken down into red in the face, and maybe coughing. If the baby digestible information by experts and their aim is Introduction of solid foods is choking, they will be silent, which is why it is to support parents through the first 1,000 days of Foods such as parsnip, carrot, apple and sweet imperative that any form of baby-led weaning is parenthood. NCT also have means of connecting potato can be blended, mashed or steamed supervised at all times.29 parents to one another through local activities into sticks for finger food. Small, round foods and meet-ups. should never be offered because there is a risk Role of the pharmacy team of choking. Food that is freshly prepared for the Pharmacists and pharmacy teams are in an Useful Resources rest of the family can be blended but must not be accessible location for healthcare advice and, Here are a few links with further information seasoned with salt. often, new parents will speak to the pharmacy on infant nutrition. A majority of the following It is recommended that a mixture of vegetables, team for any common feeding-related problems. are designed for parents, which is useful for fruit, protein, dairy and unsweetened or unsalted Beginning with non-judgemental questions, such signposting within the pharmacy. foods are incorporated. Breast milk should still as ‘how are you feeding your baby?’ as opposed • The National Childbirth Trust www.nct.org.uk be the main drink of choice until 12 months, after to ‘are you breastfeeding?’ can help the parent to • Start4Life Campaign by the NHS www.nhs.uk/ this water can be introduced or breastfeeding feel comfortable to talk about what issues they start4life/baby can continue up to two years in total. If less may be having. As previously mentioned, a lot of • The Baby Friendly Initiative by UNICEF than 500ml of formula is consumed during new mothers struggle with breastfeeding, and (transforming healthcare for babies, their weaning, then vitamins A, C and D should be pharmacies are able to offer support mechanisms mothers’ and families in the UK) www.unicef. supplemented.27 such as nipple shields, breast pads and soothing org.uk/babyfriendly According to the NHS, it can take 10 or more nipple cream. Mastitis and sore or cracked nipples • First Steps Nutrition Trust – supporting attempts at one flavour or texture for a child to are very common barriers to breastfeeding and, nutrition from pre-conception to five years old enjoy a certain food and this can vary daily.26 on the whole, are easily solved with over-the- www.firststepsnutrition.org By 9-12 months, the infant should be counter advice. Women with bleeding nipples • British Nutrition Foundation www.nutrition. consuming three healthy meals a day alongside Baby-led weaning allows infants to explore food should be referred to their GP for further advice. org.uk/healthyliving/nutrition4baby.html nutritious snacks. independently Having an understanding of different types of

chemistanddruggist.co.uk/update-plus March 2021 | Module 1971 | The role of nutrition in infants | 3 of 5 Infant nutrition logsheet CPD planned learning Take the 5-minute test online 1. Early nutrition can be important in the prevention of long-term What are you planning to learn? modifiable conditions such as obesity and cardiovascular disease. Include a specific learning objective, why this learning is relevant to your role, how the learning will affect people using True or false your services. 2. Solids should be integrated and increased as part of daily nutrition (The following examples should be used as a guide for your planned learning, you should add in specific information relevant to between 3-18 months of age. your practice and your own learning needs for this topic). True or false

Serving as the main community pharmacy for a small, rural area, it is critical that we are able to provide information and 3. The colostrum is a more dilute form of breast milk that provides guidance to new parents about feeding and nutrition for their infants. I want to develop my knowledge of the various immunity for new-borns. infant formulas available for those mothers who move on from breastfeeding, or able unable to breastfeed for various True or false reasons. 4. Approximately 40-55% of the breast milk total energy in comprised of lipids which are presented as fat lipid globules in the breast milk. How are you planning to learn it? True or false Include the learning activities you plan to undertake, make sure you consider a range of options for achieving your 5. Breastfeeding has been shown to reduce the incidence of diabetes and learning across the breadth of your CPD entries. hypertension by 30% and 13% respectively in mothers post-partum. (Other sources of information that you plan to use can be added to these learning suggestions). True or false

I plan to find out more about what barriers exist for new mothers when trying to breastfeed and what impact this can 6. Factors that may prevent breastfeeding include concurrent have on feeding for a new born or infant. Additionally, I plan to discuss the different formulas that we sell here in our chemotherapy, concurrent HIV treatment and problems with the pharmacy with our team so that we can provide structured and individualised advice to parents on nutrition for their mother’s nipple such as mastitis. babies and infants. True or false

I plan to complete the 5-minute test at www.chemistanddruggist.co.uk/update-plus to test my knowledge and confirm 7. Comfort milk includes fully hydrolysed proteins allowing for complete what I have learned. digestion in the infant. True or false Give an example of how this learning has benefited the people using your services. 8. Soya milk may not be recommended under medical supervision due Include what specific skills, attitudes and/or behaviours you have gained as a result of your learning, a real example of the impact of phytoestrogens on the development of the reproductive how the people using your services have benefited from your learning, any feedback you have had. system in infants. True or false (The following examples should be used as a guide for evidence of how your learning has been applied, you should add in examples specific to your practice of how your patients/service users have benefited). 9. Cold-water sterilising fluids should be changed every 36-48 hours. True or false A new mother who lives locally came to us for advice regarding weaning for her infant. She described some common grievances found in this scenario such as her infant being resistant to new foods and textures. We advised her that this 10. If less than 1500ml of formula is consumed during weaning, vitamins A, is completely normal, and that it can take infants up to 10 attempts with a new flavour or texture before they become C and D should be supplemented. accustomed to that food. True or false

We also provided advice on the introduction of potential allergens in slow fashion using small amounts on a repetitive basis, if tolerable. This includes ground nuts and small volumes of cows’ milk to test for potential allergies in the infant.

After another month of weaning, the mother reported that her infant was now having one regular solid meal a day, which she interchanged between various vegetables and fruits to which her infant had now become accustomed.

chemistanddruggist.co.uk/update-plus March 2021 | Module 1971 | The role of nutrition in infants | 4 of 5 References

1. The World Health Organisation (2020) Infant nutrition 16. The Royal College of Paediatrics and Child Health (2017) New breastfeeding stats published

2. British Heart Foundation (2020) Modifiable and non-modifiable risk factors 17. The World Health Organisation (2020) Infant and young child feeding

3. World Health Organisation (2020) Global nutrition targets 2025: Breastfeeding policy brief 18. NHS (2019) Breastfeeding problems

4. Nutrition.org (2018) Exploring nutrients 19. NHS (2019) Types of formula milk

5. Andreas N, Kampmann B, Mehring Le-Doare K. (2015) Human breast milk: A review on its composition 20. Palmer G. (2009) A brief history of infant milks [Internet]. firststepsnutrition; p. 1-2. and bioactivity. Early Human Development. 91:11; 629-635, 21. Public Health England (2015) A guide to bottle feeding leaflet 6. Nutrition.org. (2018) Breastfeeding 22. The National Insitute of health and Care Excellence (2013) Postnatal care 7. London: Communications International Group (2019) Pharmacy guide to infant feeding. p.17. 23. Department of Health (2013) DH guidance notes on the infant formula and follow-on formula regulations 8. Nutrition.org. ( 2018) Feeding your baby and looking after you 24. NHS (2019) Types of formula 9. American Pregnancy Association (2020) Colostrum: Superfood for your newborn baby 25. NHS (2019) Sterilising baby bottles 10. Ballard O, Morrow AL. (2014) Human milk composition: nutrients and bioactive factors. Pediatr Clin North Am. 2013;60(1):49-74. doi:10.1016/j.pcl.2012.10.002 26. NHS Start4Life (2020) Weaning

11. National Childbirth Trust (2018) About breastmilk and breastfeeding 27. Nutrition.org (2020) Introducing solid foods to your baby

12. American Pregnancy Association (2019) What’s in breast milk? - Nutrients and vitamins in breast milk 28. Centers for Disease Control and Prevention (2018) Foods and drinks to limit

13. British Society for Immunology (2020) Immunoglobulin A (IgA) 29. National Childbirth Trust (2018) Baby-led weaning: pros and cons.

14. Unicef United Kingdom (2019) Maternal health research: Meta-analyses - baby friendly initiative

15. British Specialist Nutrition Association (2017) Infant nutrition

An Update Plus Update module Practical approach Podcast Interactive quiz A typical module that allows A pharmacy-based clinical Listen to expert interviews Have a competitive edge? Try subscription you to read the content and scenario asks what you on speciality areas, from our new interactive quizzes gives you… then complete the short would do and provides Alzheimer’s to the Zika and see where you rank 5 minute quiz to test. expert advice. virus. against your peers.

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